Guest Editorial: Bridging the gap in delivery of psychological treatments for posttraumatic stress disorder.

VA Central Office, Office of Mental Health Services, Washington, DC.
The Journal of Rehabilitation Research and Development (Impact Factor: 1.43). 07/2012; 49(5):xiii-xvi. DOI: 10.1682/JRRD.2012.01.0006
Source: PubMed
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Available from: Bradley E. Karlin
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    ABSTRACT: Objective: The U.S. Department of Veterans Affairs (VA) has engaged in substantial efforts to promote the use of evidence-based psychotherapies for posttraumatic stress disorder (PTSD). The authors evaluated the effectiveness of these efforts. Methods: This study used a cross-sectional, mixed-methods evaluation of treatment provided by the VA at specialty PTSD clinics in New England during the first six months of fiscal year 2010. Natural language processing algorithms were applied to clinical notes to determine utilization of evidence-based psychotherapy (prolonged exposure therapy and cognitive-processing therapy) among patients who were newly diagnosed as having PTSD. Data regarding efforts to implement evidence-based psychotherapy and other clinic characteristics were obtained through qualitative interviews with clinical and administrative staff (N=30), and the Promoting Action on Research Implementation in Health Services framework was used to identify clinic factors associated with use of evidence-based psychotherapy. Results: Six percent of patients (N=1,924) received any sessions of an evidence-based psychotherapy for PTSD (median=five sessions). Several clinic factors were associated with an increased rate of implementation, including prior experience with use of the treatments, customization of training, and prolonged contact with the implementation and training team. Facilitation with broad training goals and clinics with highly organized systems of care were negatively associated with implementation. Conclusions: Few patients with PTSD received evidence-based psychotherapy for PTSD during their first six months of treatment at a VA specialty PTSD clinic. The implementation framework poorly predicted factors associated with uptake of evidence-based psychotherapy. These results suggest that additional research is needed to understand implementation of evidence-based therapy in mental health settings.
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    ABSTRACT: Objective: To determine differences in reported barriers to treatment completion associated with telemedicine vs. in-person delivery of evidence-based treatment for PTSD in combat veterans. Method: The present study was derived from two ongoing randomized controlled trials (RCTs) comparing in-person vs. telemedicine delivery of exposure therapy for PTSD. A one-time telephone assessment of participants who dropped out from the treatment phase of these two studies was conducted, with measures focusing on reported reasons for dropout, and perceived comfort and efficacy of the treatment modality. Dichotomous data were analyzed via chi-square and logistic regression; continuous data via ANOVA. Results: Forty-seven of 69 total dropouts participated. There was no difference in rate of dropout between modalities. A greater proportion of participants receiving in-person exposure therapy reported difficulties with logistical aspects of care (e.g., parking), whereas a greater proportion of participants receiving telemedicine therapy reported difficulty tolerating certain stressful aspects of treatment; however, those receiving telemedicine delivered treatment completed more sessions before dropping out. Participants in both conditions reported that they liked and were confident in their therapist Conclusions: Dropout reasons varied according to type of treatment delivery. Recommendations for future research are given in terms of modification of treatment protocol according to delivery modality.
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    ABSTRACT: Mindfulness has increasingly been shown to be a resilience-promoting factor against the negative effects of stress and anxiety. While there is considerable literature evidencing that higher levels of mindfulness are associated with decreased stress and anxiety in civilian cross-sectional studies, fewer studies have examined this relationship utilizing longitudinal designs with recently deployed National Guard soldiers. The present study examined the resilience-promoting effects of mindfulness on symptoms of post-traumatic stress disorder (PTSD), anxiety, and general distress with members of Aviation (N = 52) and Infantry (N = 146) battalions of the Army National Guard who recently returned from deployment. Each study participant completed measures at two time points (3 and 12 months post-deployment) to examine whether mindfulness predicted symptom reporting over time. Overall, findings suggest that time 1 mindfulness is a significant predictor of time 2 general distress, anxiety, and the hyperarousal symptom cluster, but not time 2 total PTSD. Consistent with previous studies, these findings suggest that mindfulness measures may be useful for identifying soldiers at risk and resilient for post-deployment psychological distress. The implications for different diagnostic frameworks and criteria are considered.
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